Topiramate for Obstructive Sleep Apnea and Snoring

Mr. A was a 50-year-old married engineer who had been in treatment for bipolar disorder for several years. His initial treatment was with 450 mg b.i.d. of controlled-release lithium carbonate, 75 mg/day of venlafaxine, 30 mg/day of mirtazapine, and 1 mg/day of clonazepam. He had remained on this same regimen until the present. As a result of complaints of snoring and breathing arrests, polysomnography was performed. It indicated obstructive sleep apnea of degree III, severe snoring, and a marked reduction in REM and slow-wave sleep. (Operational definitions for scoring of obstructive sleep apnea were suggested by an American Academy of Sleep Medicine task force [3]. Data to justify a severity index based on event frequency were derived from the Wisconsin Sleep Cohort.) The use of a continuous-positive-airway-pressure device was recommended, but Mr. A refused it because of financial concerns.

He began treatment with topiramate, 25 mg/day; the dose was progressively increased to 100 mg/day. My sole recommendation was the use of this medication. A remarkable reduction in snoring was reported soon thereafter; there remained only slight dorsal-decubitus snoring. A follow-up polysomnography, allowed by Mr. A’s health insurance, showed obstructive sleep apnea of degree I, moderate snoring, periodic-movement syndrome of the legs, and fragmented sleep. There was a drastic decrease (approximately 70%) in his episodes of apnea, falling from 20.0/hour to 6.6/hour. There were no changes in body weight.